NGN NCLEX Guide Book

Next Generation
NCLEX Guidebook 2022

PREPARED AND PRESENTED BY:
ATI Nursing Education
Your reference for

everything you need
to know about the new
version of the NCLEX
Scan for the most

up-to-date version
Table of contents
CLINICAL JUDGMENT 13 TEACHING STRATEGIES 50 NEW ITEM TYPES 69
COMING IN April 2023: A NEW VERSION OF THE NCLEX®......................... 6
QUICK REFRESHER........................................................................................ 7
Why a new NCLEX is needed now............................................................................................. 7
NCSBN research & reasoning.................................................................................................... 8
The NCSBN’s steps to create a new exam................................................................................. 9
The purpose of the Special Research Section.......................................................................... 11
Timeline for NGN’s launch.......................................................................................................12
CLINICAL JUDGMENT.................................................................................. 13
Its impact on public safety........................................................................................................ 13
NCSBN’s official definition....................................................................................................... 15
Evidence-based advice............................................................................................................ 16
Using effective techniques....................................................................................................... 17
Practical teaching tips.............................................................................................................. 19
Tips on the Socratic Method.................................................................................................... 22
Focus on priority setting........................................................................................................... 24
Maslow’s Hierarchy of Needs (item example & rationales)................................................... 25
Airway-Breathing-Circulation (item example & rationales)................................................... 26
Safety & Risk Reduction (item example & rationales)........................................................... 27
The Nursing Process (item example & rationales)................................................................ 28
Least Restrictive/Least Invasive (+ item example & rationales)............................................ 30
Acute vs. Chronic/Unstable vs. Stable/Urgent vs. Nonurgent (item example & rationales).31
Survival Potential (item example & rationales)..................................................................... 34
Table of contents (continued)
PREPARING FOR THE NEW VERSION OF THE EXAM................................ 36
Step 1: Don’t automatically change the current curriculum you use........................................ 36
Step 2: Ensure clinical judgment is part of your lessons.......................................................... 37
Step 3: Understand the NCSBN’s Clinical Judgment Measurement Model (NCJMM)............ 38
Step 3a: Review the six functions of clinical judgment in Layer 3....................................... 39
Step 3b: Review the environmental and individual factors in Layer 4................................. 40
Step 4: Teach your students about clinical judgment.............................................................. 41
Step 5: Identify activities you can use to help students develop skills for each phase............ 42
Function 1: Recognize cues (assessment)............................................................................ 44
Function 2: Analyze cues (analysis)...................................................................................... 45
Function 3: Prioritize hypotheses (analysis)......................................................................... 45
Function 4: Generate solutions (planning).......................................................................... 46
Function 5: Take actions (implementation).......................................................................... 47
Function 6: Evaluate outcomes (evaluation)........................................................................ 48
STRATEGIES TO TEACH CLINICAL JUDGMENT.......................................... 50

Use NCSBN’s action model template....................................................................................... 50
Create learning outcomes........................................................................................................ 51
Strategies in the classroom...................................................................................................... 53
Activity: Collecting cues...................................................................................................... 53
Activity: Problem identification........................................................................................... 54
Activity: Tree of impact........................................................................................................ 55
Strategies in the lab/simulation................................................................................................ 57
Activity: Health assessment................................................................................................. 57
Strategies in clinical.................................................................................................................. 58
Activity: Change-of-shift report........................................................................................... 58
Strategies in clinical/simulation................................................................................................ 59
Activity: Clinical judgment case study................................................................................. 59
Activity: Clinical and simulation strategy journal ................................................................ 60
Table of contents (continued)
DETAILS ABOUT THE NEW EXAM............................................................... 63
The length of the Next Gen NCLEX......................................................................................... 64
Time required to answer new item types............................................................................ 65
Reminders about the NCLEX.............................................................................................. 66
Differences between the current NCLEX & the NGN.............................................................. 67
What won’t change............................................................................................................. 67
What will change................................................................................................................. 68
New item types on the NGN.................................................................................................... 69
An introduction to the case study....................................................................................... 70
The format of case studies.................................................................................................. 71
An introduction to stand-alone items....................................................................................... 73
Sample of a bow-tie stand-alone item................................................................................ 74
The different formats of case study and trend item types........................................................ 75
Matrix item type.................................................................................................................. 76
Highlight item type............................................................................................................. 77
Drag-and-drop item type.................................................................................................... 78
Multiple-response item type............................................................................................... 79
Drop-down item type.......................................................................................................... 80
Differences in scoring the Next Generation NCLEX................................................................ 82
How new item types will be scored..................................................................................... 82
DEVELOPING & ASSESSING CLINICAL JUDGMENT SKILLS....................... 83

The art and science behind assessments................................................................................. 83
An overview: Assessment development................................................................................... 84
Testing & equating of assessments.......................................................................................... 86
Test security for proactive protection....................................................................................... 87
Clinical judgment tools for development & assessment.......................................................... 88
ATI tools in development + available now............................................................................... 91
HOW TO STAY UP-TO-DATE & GET YOUR QUESTIONS ANSWERED......... 93

Stay up-to-date on Next Gen NCLEX...................................................................................... 93
Get all your questions answered about NGN.......................................................................... 94
5
Coming in April 2023:
a new version of the NCLEX
We’ve gathered everything you need to know so

you can prepare for the Next Generation NCLEX.
The National Council of State Boards Note: The information in this guide
of Nursing (NCSBN) has announced was current at the time of publication,
a definitive date for the launch of the but the NCSBN regularly releases
Next Generation NCLEX: April 2023. new details on the NGN. For the most
With just that date nearing, the organization current info, visit ATItesting.com/
also has been actively sharing more educator/next-gen-nclex or NCSBN.org.
detailed information about the exam.
You can also download the most
This guide provides the most up- current version of this publication by
to-date and clearly explained scanning the QR code on the cover.
information currently available.
Share it with colleagues to help them

prepare for this momentous change.
6
Quick refresher:
why a new NCLEX is needed now
Nurses face more complex client needs

in a rapidly changing healthcare environment.
When you were in nursing school, The NCSBN confirmed this

your instructors probably didn’t reality by viewing new nurses
talk about clinical judgment — at at work. This observational
least not using that term. So why practice analysis verified how
is it important to assess this often new nurses use clinical
skill today? judgment in their daily tasks
in today’s practice settings.
Because healthcare is now The organization realized it was
much more dynamic. It moves critical to change the NCLEX
at a rapid pace. And nurses so that the exam can accurately
now care for people with more assess candidates’ clinical
acute, complex, chronic illnesses judgment skills to ensure
that require completely new public safety.
technology.
Read more about the impact on

7 public safety on page 13.
NCSBN research
& reasons for creating a new test
The plan for the Next Generation NCLEX has

been in the works for many years.
In 2009, the NCSBN held The NCSBN’s studies underscored

conversations with professionals that recent data. Its research showed
in clinical practice and nursing clinical judgment is one of the top
experts. They determined that five skills required to enter nursing
the current level of decision- practice. Two other high-priority
making in nursing had led to a skills were problem-solving and
large number of practice errors critical thinking, which are both vital
by entry-level nurses. to clinical judgment. (The other two
required skills were active listening
Since then, the problem has and professional communication.)
only gotten worse. An article
by Kavanagh and Sharpnack The RN Nursing Knowledge Survey
(2021) said that 2016-2020 data from 2017 offered more evidence of
showed only 14 percent of new the need for clinical judgment. Newly
graduate RNs demonstrated licensed RNs, RN supervisors, and RN
entry-level competencies. Worse, educators unanimously agreed on
2020 year-to-date graduate the importance of clinical judgment.
data from 200 unique schools PN experts shared the same concerns.
of nursing displayed an even
more disturbing decline: Only 9 As a result of these findings, the
percent of new RN grads ranked NCSBN determined it was vital
in the acceptable competency to move forward with the Next
range for a novice nurse. Generation NCLEX (NGN) Project.
8
The NCSBN’s steps
to create a new exam
Research is the backbone of the NCSBN’s plan.
The NCSBN’s team of researchers and

psychometricians have followed eight
evidence-based steps to prepare for
the new version of the exam:
9
NCSBN steps
1) DEVELOP A CLINICAL 5) RESEARCH MEASUREMENT

JUDGMENT MODEL Psychometricians have received
The NCSBN developed a model of millions of data points from the
five interacting layers that illustrate the responses to the “Special Research
complex process of clinical judgment, Section.” Ongoing analysis has
including the context in which decisions been determining which item types
are made. (See page 38.) accurately measure clinical judgment
and nursing competence.
2) CREATE ITEM PROTOTYPES
Measuring clinical judgment requires 6) BUILD TECHNOLOGY
more unique item types than simple The NCSBN is now developing the
multiple-choice questions, as well complex technology needed to
as different scoring methodologies, support the new item types.
including one that deducts points
for incorrect responses. 7) PERFORM ALPHA/BETA TESTS
Multiple evaluations are necessary
3) TEST ITEM USABILITY to assess test items. The NCSBN is
Students, nurses, and educators have scrutinizing every item type for those
reviewed item prototypes to ensure providing the highest accuracy.
they represent real-life clinical
judgment scenarios. 8) LAUNCH NEW NCLEX
After the operational phase of testing
and building item types, the Next
4) COLLECT ITEM DATA
Generation NCLEX is scheduled to
The NCSBN added a “Special Research
launch in April 2023.
Section” with new item types for some
students to voluntarily answer after
completion of the current NCLEX. Their
responses didn’t impact their scores
but did provide valuable insight on
question validity.
10
The purpose
of the Special Research Section
This section of the current NCLEX is a crucial

factor in developing the NGN.
Starting in July 2017, the NCSBN The NCSBN says, “This research
began including a Special helps identify Next Generation
Research Section (SRS) as part of NCLEX (NGN) items that are at
the NCLEX-RN exam for select the appropriate difficulty level
candidates. In October 2020, it for entry-level nurses — items
began offering an SRS to select that are neither too difficult
PN candidates. nor too easy. The research
section also helps gather data
The SRS presents unique item related to the time required to
types that are specially designed respond to the new NGN items.
to evaluate the candidate’s Validating both the content and
clinical judgment skills. the measurement properties of
items is essential to developing a
Candidates receive 30 minutes
standard-leading assessment of
to complete the SRS after their
clinical judgment.”
standard NCLEX exam with no
impact on their NCLEX score.
Candidates’ answers provide data

to the NCSBN for use in testing
and analyzing the new item types.
11
Timeline
for NGN’s launch
DECEMBER 2022 APRIL 1, 2023 APRIL 2023

“Live” beta testing takes place. The new test plan launches. (To be determined)
Actual candidates who are The Next Generation
There will not be a separate test plan
expected to graduate in April for the NGN. It is all-encompassing NCLEX launches.
2023 will take a fully functioning within the RN or PN Test Plan.
The NCSBN plans to launch the NGN
exam, but scoring and results will for RNs and PNs simultaneously.
not count. Resulting data will be
for internal NCSBN quality control
purposes to ensure validity and
reliability of the exam.
12
Clinical judgment
& its impact on public safety
Clinical judgment is necessary when

caring for the complex needs of clients.
The NCSBN’s observational What was especially worrisome

practice analysis showed that to the NCSBN was the data that
the linking factor in almost any new nurses were regularly making
task that an entry-level nurse errors, and 60 percent of them
performed was the ability were directly related to clinical
to make judgments on the judgment. About half of the errors
spot based on the evidence led to remediation or disciplinary
presented. action. This knowledge is
important because clinical errors
Phil Dickison, PhD, RN, the quite often affect client safety and
NCSBN’s Chief Officer of lead to client harm.
Operations & Examinations,
explained, “Many of these It was clear to the NCSBN that
judgments … have the biggest assessing clinical judgment
impact in urgent or emergent in nursing candidates was
situations.” imperative.
13
DR. PHIL DICKISON
NCSBN Chief Officer

of Operations & Examinations
“A decade of performance-based development

system assessments representing more than
10,000 new graduate RNs reveals an alarming
year-over-year decline in initial competency.“
Kavanagh, Sharpnack, 2021
14
Clinical judgment:
NCSBN’s official definition
Help students understand what it means.
The NCSBN has defined clinical judgment

for the nursing profession as “the observed
outcome of critical thinking and
decision-making.”
Further, clinical judgment is an iterative

decision-making process that uses nursing
knowledge to:
•O
bserve and assess presenting
situations
• Identify a prioritized client concern
•G
enerate the best possible evidence-
based solutions in order to deliver safe
client care.
15
Clinical judgment:
evidence-based advice
Research provides insights on how to incorporate

clinical judgment in lessons.
• In cases where students face limitations in credit • Show students why tasks require problem
hours and clinical sites, use unfolding case solving, critical thinking, and clinical judgment.
studies to develop clinical judgment given the (NCSBN, 2018)
established link between dynamic case studies
and clinical practice experience. Simulation • Focus on six instruments that measure clinical
can also play a role in developing sound clinical judgment: simulation-based experience
judgment. Shatto et al (2017) demonstrated exposures, specific nursing specialty simulations,
that at least three simulation experiences can debriefing and its effect on clinical judgment,
contribute to significant clinical judgment assessment, clinical decision-making, and
development in nursing students. reflection. (Klenke-Borgmann, et al, 2020)
(Hussein et al, 2021)
• Use concept-based strategies that engage
• Have students review encounters in an unfolding students in deliberate practice with concepts
clinical scenario. Ask students to provide as they manifest in a variety of contexts.
evidence-based responses and behaviors based This technique will increase the number of
on the associated clinical judgment functions. experiences upon which students can draw to
(See page 41.) This strategy allows educators to reason through patient situations. (Jessee, 2021)
promote deep learning, foster the development
of clinical judgment, and evaluate student
learning. (Sommer et al. 2021)
Learn more:
Sommer, S.K., Johnson, J.D., Clark, C,M,, Mills, C.M. Manetti, W. (2018). Sound clinical judgment in nursing:
Assisting learners to understand and incorporate A concept analysis. Nursing Forum, 54(1), 102-110.
functions of clinical judgment into nursing practice. https://doi.org/10.1111/nuf.12303
Nurse Educator. 2021;46(6):372-375. doi: 10.1097/
NNE.0000000000001020 Hussein, M., Olfert, M. & Hakkola, J. (2022). Clinical
judgment conceptualization scoping review protocol.
Jessee, MA. (2021). An update on clinical judgment in Teaching and Learning in Nursing, 17, 84-101. https://
nursing and implications for education, practice, and doi.org/10.1016/j/teln.2021.10.003.
regulation. Journal of Nursing Regulation, 12(3), 50-60.
DOI:https://doi.org/10.1016/S2155-8256(21)00116-2 Jessee, M. A. (2021). An update on clinical judgment
in nursing and implications for education, practice, and
Dickison, P., Haerling, K.A., & Lasater, K. (2019). regulation. Journal of Nursing Regulation. 12(3), 50-57.
Integrating the National Council of State Boards
of Nursing clinical judgment model into nursing Klenke-Borgmann, L., Cantrell, M. & Mariani, B. (2020).
educational frameworks. Journal of Nursing Education, Nurse educators’ guide to clinical judgment: A review
58(2), 72-78. https://doi.org/10.392801484834- of conceptualization, measurement, and development.
20190122-03. Nursing Education Perspectives, 41(4), 215-221.
https://doi.10/1097/01.NEP0000000000000669.
NCSBN (2018). Strategic practice analysis. NCSBN
Research Brief, 7,11-15.
16
Using effective techniques
Adopt teaching techniques based on research.
Based on the research noted on • Deliver one-on-one interaction

the previous page, use these and coaching.
techniques to help students
develop their clinical judgment: • Encourage interaction with
other healthcare team members.
• Emphasize what is most
important. • Incorporate quality feedback that:
º Is timely and specific
• Use cognitive and experiential º Identifies strengths/deficits
strategies — active learning — º Shares alternative perspectives
that promote higher-level º Recommends ways to improve.
thinking, such as thinking
aloud and reflection.
• Make assignments that are

appropriate yet realistic for the
students’ level.
17
Notes
Clinical judgment:
practical teaching tips
19
Teaching tips
Help students develop clinical judgment skills

in three primary ways.
1) USE ACTIVE-LEARNING STRATEGIES.

The use of a variety of active-learning
strategies promotes the necessary deep-
thinking skills required for developing clinical
judgment. Incorporate case studies, video
scenarios, and simulation to help students
better grasp the concepts being addressed
in the classroom.
2) THOROUGHLY ASSESS
ALL ASSIGNMENTS.
Make sure any assignment you give students
is relevant and challenging yet realistic for the
level of your learners. Your goal should be to
increase their curiosity and motivation so they
thoughtfully complete the work.
3) QUESTION USING THE

SOCRATIC METHOD.
This back-and-forth question-and-answer
technique is recognized for promoting
deep thinking. Require students to examine
collected data, compare and contrast findings,
provide rationales for their responses, and
explain interrelationships.
20
Notes
Tips on the Socratic Method
Ask insightful questions to elicit deeper
thinking about a topic
Socratic questioning is a technique that is especially useful in helping
students develop their clinical judgment skills. In essence, you ask a
question specifically designed to elicit discussion that clarifies information,
justifies a student's response, or probes further.
CLARIFICATION JUSTIFICATION PROBING

• “Tell me what you found during • “What prompted you to collect • “Describe implications of the
the client assessment." that data during your assessment findings.”
• "What is the client’s priority assessment?” • “Explain your thinking about
health problem?” • "What evidence supports this selecting this as the priority
as the client’s priority problem.”
problem?”
22
Notes
Clinical judgment:
focus on priority setting
Priority setting is directly related to clinical

decision-making and clinical judgment.
Students can improve their Strategies to help students improve their skills
skills for prioritizing care by in prioritizing care include:
understanding priority-setting • Use of priority-setting NCLEX items as
frameworks. In doing so, they will tools in the classroom or clinical post
inherently improve their clinical conference
judgment skills. • Screen-based simulations or videos with
clinical scenarios that require students to
Priority-setting frameworks respond based on a particular priority-
include (see following pages setting framework
for details): • Use of priority-setting frameworks in
classroom activities such as case studies.
• Maslow’s Hierarchy of Needs
• The Nursing Process Some priority-settings questions you
• Airway-Breathing-Circulation can use are:
• Safety & Risk Reduction • Which of the following actions should the
• Least Restrictive/ nurse initiate first?
Least Invasive • Which of the following assessment
• Acute vs. Chronic / Unstable findings should the nurse report to
vs. Stable / Urgent vs. the provider immediately?
Nonurgent • Which of the following clients should
the nurse assess first?
• Which of the following is the next action
the nurse should take?
24
Priority-setting frameworks
Maslow's Hierarchy of Needs

This framework contains five levels of prioritized needs. (See diagram below.)
Physiological needs supersede the others in most circumstances. However,
all client factors should be considered before determining need order.
S E L F - A C T U A L I Z AT I O N
ITEM EXAMPLE
A nurse is planning care for a SELF-ESTEEM
LOVE &
client who has bipolar disorder and BELONGING
is experiencing an acute manic
episode. Which of the following is
the highest priority intervention the
nurse should include in the plan
of care?
A. Give the client simple

directions for completing ADLs.
B. Offer the client high-calorie SAFETY &
fluids frequently. SECURITY
C. Provide the client with
structured solitary activities. PHYSIOLOGICAL
D. Keep the client’s valuables in a
locked area.
RATIONALES
A. Clients who are having an acute manic episode are likely to have poor concentration and
difficulty completing routine tasks. Providing simple directions for completing ADLs helps the
client focus; however, the nurse should take another action first.
B. The priority action for a client who is experiencing an acute manic episode is to meet the
client’s physiological need for food and water. Therefore, the priority intervention is to offer the
client high-calorie fluids frequently to prevent calorie deprivation and dehydration.
C. Clients who are having an acute manic episode are likely to have difficulty focusing on any one
activity. Providing the client with structured solitary activities helps provide focus and feelings of
security; however, the nurse should take another action first.
D. Clients who are having an acute manic episode are likely to give away their valuables. Keeping
the client’s valuables in a locked area prevents the client from doing so; however, the nurse
should take another action first.
25
Airway – Breathing – Circulation

Often called the ABCs, this framework is always the priority for initial assessments
when the client's life is at stake as all three attributes are essential for survival.
ITEM EXAMPLE
A nurse is caring for a client who is
wheezing and gasping for breath just
after receiving a dose of amoxicillin.
1ST
Airway
Which of the following actions is the

nurse’s priority?
A. A
dminister epinephrine
2 ND
Breathing
parenteral injection.
B. Provide reassurance to the client.
C. Initiate an IV infusion of 0.9%
sodium chloride.
3RD
Circulation
D. Place client on a cardiac monitor.
RATIONALES
A. Using the airway, breathing, circulation priority framework, the nurse’s priority is to give the
client an injection of epinephrine, which will counteract the bronchoconstriction.
B. The nurse should reduce the client’s anxiety by providing reassurance; however,
the nurse should perform another action first.
C. Starting an IV infusion of 0.9% sodium chloride is important to maintain fluid balance and
provide venous access; however, the nurse should perform another action first.
D. Attaching the client to a cardiac monitor is important, because medications used to

treat anaphylaxis can cause tachycardia and dysrhythmias; however, the nurse should
perform another action first.
26
Safety & Risk Reduction

This framework establishes priority based on which situation poses the greatest threat
to the client at that time. When multiple risks are present, another priority-setting
framework, like the ABCs, may need to be used to identify the highest priority.
ITEM EXAMPLE R I S K A S S ES S M EN T
A nurse is planning care for a client
who is experiencing acute alcohol
withdrawal. Which of the following
medications should the nurse plan
Safety risk to client
to administer first?
A. Disulfuram
B. Lorazepam
C. Clonidine
Greatest risk to client
D. Atenolol.
Significance of risk
compared to other risks
RATIONALES
A. Disulfuram is given to support abstinence from alcohol and prevent relapse; however,
this is not the greatest risk to the client at this time.
B. The greatest risk to the client during acute alcohol withdrawal is seizures. Therefore, the
nurse should first administer lorazepam to control or minimize seizures.
C. Clonidine can help minimize the autonomic symptoms that occur with acute alcohol
withdrawal; however, these are not the greatest risks to the client at this time.
D. Atenolol can help minimize the autonomic symptoms that occur with acute alcohol
withdrawal; however, these are not the greatest risks to the client at this time.
27
The Nursing Process

This framework is a four- or five-step process (differing between PNs and RNs)
that nurses use for decision-making. It helps determine priority nursing actions
based on the steps below and always starts with data collection/assessment.
PN: 4 Steps RN: 5 Steps

ITEM EXAMPLE
A nurse is caringAfor SSE
anSSM ENT
adolescent D ATA C O L L E C T I O N A S S E S S M E NT
who is to undergo anFIRST open reduction FIRST FIRST
and internal fixation of the ankle
following a sports injury. The client
is extremely anxious Analysis
and having Planning Analysis
difficulty sleeping. Which of the
following is the priority intervention?
Planning Implementation Planning
A. P rovide dim lighting in the
client’s room.
B. A
llow the client’s family to Implementation
Implementation Evaluation
spend the night with him.
C. Offer music as a distraction.
D. Ask the client to tell you what
Evaluation Evaluation
he knows about the procedure.
RATIONALES
A. Providing dim lighting in the client’s room can promote sleep for some clients; however,
the nurse should take a different action to address the client’s anxiety.
B. Allowing the client’s family to stay with him can help reduce his anxiety; however,
the nurse should take a different action to address the client’s anxiety.
C. Offering music as a distraction can help reduce his anxiety; however, the nurse should take
a different action to address the client’s anxiety.
D. The first action the nurse should take is to assess the client. By determining the client’s
understanding of the procedure, the nurse can provide information needed to help decrease
the client’s anxiety.
28
Notes
LE
Priority-setting frameworks AS
VE
T
RE A SI
STRIC
TIVE /INV
Least Restrictive / Least Invasive

This framework sets priorities based on the interventions that are the least
restrictive or invasive to the client to minimize the risk for harm to the client.
TRICTIVE /IN
RES VA
ST SIV
ITEM EXAMPLE L EA E
A nurse is caring for a client who gave birth
vaginally 8 hours ago. The client reports
feeling weak and dizzy. The nurse notes
that the client’s perineal pad is soaked
with blood. Which of the following
actions should the nurse take first? MOST
RESTRICTIVE/INVASIVE
A. A dminister oxygen at
10 L/minute via face mask.
B. Insert an indwelling
urinary catheter.
C. Massage the fundus
of the uterus.
D. Administer oxytocin 20 units LE E
AS IV
in 1000 mL of lactated ringers. T R AS
ESTR V E / I NV
ICTI
RATIONALES
A. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as
dizziness and weakness. The nurse may need to administer oxygen; however, the nurse should
perform a less-invasive intervention first.
B. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as

dizziness and weakness. The nurse may need to insert an indwelling urinary catheter; however,
the nurse should perform a less-invasive intervention first.
C. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as

dizziness and weakness. When providing client care, the nurse should first use the least-invasive
intervention; therefore, the first action the nurse should take is to massage the client’s fundus.
D. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as

dizziness and weakness. The nurse may need to administer oxytocin; however, the nurse should
perform a less-invasive intervention first.
30
Acute vs. Chronic / Unstable vs. Stable /

Urgent vs. Nonurgent
These three frameworks establish the priority need based on the client condition and
may be used when the other frameworks do not apply to the client-care situation.
ACUTE VS. CHRONIC

Addressing acute problems before
chronic problems is important
because there is a great risk posed
for acute problems. Acute VS Chronic
UNSTABLE VS. STABLE

Unstable clients pose a greater
threat than stable clients and need
to receive care first.
URGENT VS. NONURGENT

Urgent needs pose a greater threat
to a client than a nonurgent need.
ACUTE VS. NONACUTE RATIONALES

ITEM EXAMPLE A. Macular degeneration is a chronic condition that responds
A nurse is receiving a hand-off report to medication; although the nurse should assess the client to
at the beginning of the shift for four determine why he does not want to take his medication,
clients. Which of the following clients the nurse should assess another client first.
should the nurse assess first?
B. An HbA1c reflects a client’s blood glucose over the past three
A. A client who has macular months; therefore, the nurse should assess another client first.
degeneration and does
C. Exophthalmos is an expected finding for a client who has
not want to take his medication.
Graves' disease; therefore, the nurse should assess another
B. A
client who is taking insulin
client first.
and has an HbA1c of 7%.
C. A client who has Graves' D. The nurse should recognize that anorexia is a possible
disease and has exophthalmos. indication of digoxin toxicity. Therefore, the nurse should
D. A client who is taking assess this client first.
digoxin and is experiencing
anorexia.
31
UNSTABLE VS. STABLE ITEM EXAMPLE
A nurse is reviewing laboratory data for four clients. Which of the following
clients should the nurse assess first?
A. A client who has atherosclerosis with a total cholesterol level

of 250 mg/dL.
B. A client who has chronic kidney disease with a BUN of 80 mg/dL.
C. A client who is receiving warfarin with an INR of 4.0.
D. A client who is receiving furosemide and has a serum potassium
of 3.8 mEq/L.
RATIONALES
A. The nurse should continue to monitor the client who has atherosclerosis and an
elevated total cholesterol level; however this client is stable and does not need to be
assessed first.
B. The nurse should continue to monitor the client who has chronic kidney disease and
an elevated BUN; however this client is stable and does not need to be assessed first.
C. A client who is receiving warfarin and has an INR of 4.0 is at risk for hemorrhage. The
nurse should assess this client first.
D. The nurse should continue to monitor the client who is receiving furosemide and has
a potassium level within the expected reference range; however this client is stable and
does not need to be assessed first.
32
URGENT VS. NONURGENT ITEM EXAMPLE
A nurse is caring for a client who has peripheral arterial
disease. Which of the following findings should the nurse
report to the provider immediately?
A. Report of intermittent claudication

B. Shiny, hairless lower extremities
C. Absent dorsalis pedis pulse
D. Dependent rubor.
RATIONALES
A. Report of intermittent claudication is an important finding; however, it is common
for clients with peripheral arterial disease to have this type of pain.
B. Shiny, hairless lower extremities is an important finding; however, clients with

peripheral arterial disease usually develop this from long-term impaired circulation.
C. The nurse should recognize that an absent dorsalis pedis pulse can indicate acute
arterial occlusion, which requires immediate intervention.
D. Dependent rubor is an important finding; however, clients with peripheral arterial

vascular disease usually develop this from long-term impaired circulation.
33
Survival Potential
This is a triage system used during mass-casualty events to determine priorities
of care for all injured clients.
Triage categories
Gray triage tag color

EXPECTANT/
• Victim unlikely to survive given severity of injuries,
URGENT level of available care, or both.
• Palliative care and pain relief should be provided.
Red triage tag color

• Victim can be helped by immediate intervention
URGENT/ and transport.
IMMEDIATE • Requires medical attention within minutes for
survival (up to 60).
• Includes compromises to patient’s Airway,
Breathing, Circulation.
Yellow triage tag color

EMERGENT/
• Victim’s transport can be delayed.
DELAYED • Includes serious and potentially life-threatening
injuries, but status not expected to deteriorate
significantly over several hours.
Green triage tag color

NONURGENT/ • Victim with relatively minor injuries.
MINOR • Status unlikely to deteriorate over days.
• May be able to assist in own care:
“walking wounded.”
34
ITEM EXAMPLE
A nurse is assessing clients at a
mass-casualty event and placing the
appropriate triage tag on each client.
Which of the following tags should
the nurse assign to a client with an
abdominal wound that has eviscerated?
A. Class I “emergent” tag

B. Class II “urgent” tag
C. Class III “nonurgent” tag
D. Class IV “expectant” tag
RATIONALES
A. A class I emergent tag indicates the client has injuries that are life-threatening and need
immediate attention; therefore, the nurse should issue an emergent tag to this client.
B. A class II urgent tag indicates the client has injuries that need attention but are not life-
threatening; therefore, the nurse should not issue an urgent tag to a client who has an
abdominal wound that has eviscerated.
C. A class III nonurgent tag indicates the client has minor injuries that do not need
immediate treatment; therefore, the nurse should not issue a nonurgent tag to a client who
has an abdominal wound that has eviscerated.
D. A class IV expectant tag indicates the client has injuries that are not consistent with life;
therefore, the nurse should not issue an expectant tag to a client who has an abdominal
wound that has eviscerated.
35
Preparing for
the new version of the exam
Step 1: Don't automatically change the current curriculum you use.
The introduction of a new From July 2017 through December

version of the NCLEX does 2018, NCSBN had more than
not mean you need to change 340,000 individuals interact
your core curriculum. The with new item types designed
new version of the NCLEX is to measure clinical judgment, he
simply a measurement tool explained.
designed to assess the way
students think. Thus, you do All of those students had been
not need to completely revise educated using a variety of nursing
your curriculum, whether it is curricula. And, no matter which
traditional or concept-based. curricula from which the student had
learned, the impact was the same:
How does the NCSBN know Students who performed well on the
your current curriculum will regular NCLEX also performed well on
be sufficient in preparing the NGN-style items and vice versa.
students for the new exam?
The organization explained in
the following statement from
Dr. Dickison:
36
Preparing for the new version of the exam
Step 2: Ensure clinical judgment is part of your lessons.
This information was touched on previously, but it can't be

emphasized too much.
To encourage the development of clinical judgment, make

it a critical curriculum component.
Incorporate it into:
STUDENT LEARNING TEACHING RESOURCES AND TOOLS

OUTCOMES Incorporate learning activities that require
clinical judgment.
STUDENT ASSIGNMENTS
Provide multiple opportunities to STUDENT ASSESSMENTS
develop clinical judgment skills. Incorporate iteration into assessments by
Give students experience with adding new information to unfold the clinical
real-life scenarios/case studies. situation forcing re-evaluation throughout
the process rather than waiting until the end.
CURRICULUM EVALUATIONS Students need to know what gaps exist in
Review student acquisition of their understanding even if they ultimately
clinical judgment skills. reach the correct decision. Understanding why
the other choices in a question were wrong
is also a helpful learning tool for students.
The NCSBN’s Clinical Judgment SPRING 2021
Next Generation
Measurement Model is a crucial NCLEX NEWS
®
part of understanding the

Next Generation NCLEX®: Stand-alone Items
The Next Generation NCLEX® News is a quarterly publication that provides the
latest information about the research being done to assess upcoming changes to
the NCLEX Examinations. In this issue, you will find information related to Next
NGN. Read more about it

Generation NCLEX (NGN) stand-alone items.
Stand-alone items are individual items that may contain multiple steps from Layer 3 and
aspects of Layer 4 of the NCSBN Clinical Judgment Measurement Model (NCJMM) (Spring 2020,
Summer 2020). Two types of stand-alone items are included in the NGN-RN and NGN-PN Special
on the next page and in the

Research Sections (SRSs), bow-tie items and trend items.
The following chart explains the differences between a stand-alone item and a case study.
Has a stated diagnosis or an implied diagnosis

Includes clinical information for a specific client
Stand-alone
Item
NCSBN’s “Next Generation

Provides components that require the entry-level nurse to make
one or more clinical decisions
Has clinical information for one or more clients

Is a group of six items that represents the NCJMM
Requires the entry-level nurse to make multiple clinical decisions
Case Study
NCLEX News” publication.

throughout the spectrum of the clinical judgment model
Uses an action-model approach by combining individual
components in a structured format
37 Continued on next page

Step 3: Understand the NCSBN’s Clinical Judgment Measurement Model.
The NCSBN's Clinical Judgment Here's how the NCSBN describes the NCJMM's
Measurement Model (NCJMM) was created relationship to the nursing profession:
to help evaluate candidates' clinical judgment.
The NCSBN has been using the NCJMM to "Layers 3 and 4 of the NCJMM delineate the cognitive
develop the new item types that will appear process of how a nurse makes decisions for Layer 2. Based
on the Next Generation NCLEX. (If you’ve on the client’s response from Layer 2, either satisfactory
used a contextual unfolding case study or unsatisfactory, the nurse can move through the entire
before, then you may see similarities in the cognitive processes of Layers 3 and 4 again. The entirety of
new item types.) nursing clinical judgment in Layer 1 subsequently impacts
the clinical decision for the client’s needs at Layer 0."
The diagram illustrates the “layers” of the NCJMM

starting from the broadest layer (0) defining the
context of the clinical situation and leading
to the most specific contextual layer (4).
Client Clinical
needs decisions
Layer 0
Clinical judgment
Layer 1
Satisfied
Not satisfied
Form hypotheses Refine hypotheses Evaluation
Layer 2
Recognize Analyze Prioritize Generate Take Evaluate

cues cues hypotheses solutions actions outcomes
Layer 3
Environmental factor examples Individual factor examples
Client Medical
Environment Resources Knowledge Skills Specialty
observation records
Consequences Time Task Cultural Candidate Prior Level of

& risks pressure complexity consideration characteristics experience experience
Layer 4
Nursing
Process
38 Assessment Analysis Planning Implementation Evaluation

Step 3a: Review the six functions of clinical judgment in Layer 3
In considering the education and testing the skills and

knowledge of entry-level nurses, the NCSBN believes
it is essential to focus on Layer 3 of the NCJMM.

The six steps in this layer involve The NCSBN emphasizes:

a repetitious process the nurse “Any evidence-based
moves through with each curriculum that teaches
client. This process is iterative, clinical judgment effectively
meaning the nurse can gain will provide students with
new information or cues while preparation necessary for the
assessing or treating a client. new components of the exam.”
This new information can cause
the nurse to return to a previous
function and then move through
the process again, continuously
re-evaluating.
39
Step 3b: Review the environmental and individual factors in Layer 4
To further help nursing students understand the aspects of their job that
affect their clinical judgment, the NCSBN developed Layer 4. This layer
identifies additional factors that impact the clinical situation.
Considering these environmental and individual factors is crucial to ensuring

a nurse makes an appropriate clinical decision.
Some examples of these factors are:
ENVIRONMENTAL • C ultural considerations (i.e., language,

• S etting, situation, and literacy, religion, diet)
environment (i.e., safety • Task complexity (i.e., level of difficulty,
considerations, equipment, complicated versus simple action, number
surroundings) of people involved, sound delegation)
• Client observation (i.e., age, • Risk assessment (i.e., identifying and finding
symptoms of health alteration) ways to remove or minimize harm to
• Resources (i.e., staffing, promote safety and health).
supplies, beds, care partners)
INDIVIDUAL
• Health records (i.e., history,
• N ursing factors (i.e., knowledge,
labs, diagnostic tests, I&O,
skills, specialty)
medications, treatments)
• Nurse characteristics (i.e., attitudes, prior
• Time pressure (i.e., pager,
experience, level of experience)
STAT medication, change
• Cognitive load (i.e., demands on the nurse,
in client condition)
stress, problem solving, memory)
Environmental factor examples Individual factor examples
Client Medical
Environment Resources Knowledge Skills Specialty
observation records
Consequences Time Task Cultural Candidate Prior Level of

& risks pressure complexity consideration characteristics experience experience
40
Step 4: Focus on creating clinical judgment activities.
Many educators have been It’s a decision your faculty should make and then
concerned about how to explain be consistent in how they introduce the model.
the NCJMM to students. It Whichever way you choose, introduce Layer
admittedly is a complicated- 3 (see below) early. It simplifies the process of
looking graphic. You may decide understanding the iterative nature of the clinical
to wait to mention the model to judgment process.
your students until they are further
along in your program, while
others may decide to introduce
it early and talk about it often.

Explain how the functions of developed by ATI and included in the "ATI
clinical judgment in the model Guide for Clinical Judgment." (Read about
align with the nursing process the research behind the guide1.)
your program uses by showing
students an easy-to-understand Point out the relationship between the nursing
illustration — “The relationship process and clinical judgment and how they
of approaches fostering work in tandem to help nurses deal with
clinical judgment” complex clinical situations.
(see following page) —
41
The relationship of approaches

fostering clinical judgment
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Analyze (Clinical judgment functions)
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Take cues
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AN
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Tanner’s Clinical
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Copyright 2021, Assessment Technologies Institute, LLC
Step 5: Identify activities you can use to help students

develop skills for each function of the clinical judgment model.
Building on the advice regarding To help, the following pages identify aspects of
teaching techniques and tips each function to help you create a variety
mentioned on pages 17, you of learning activities.
can start to create more specific
activities that enhance the Read on to find out more about:
development of each function • The step of the Nursing Process with
of clinical judgment. which each function aligns
• A definition of each function
As you create activities, pay • Suggestions for activities for each functione.
attention to the appropriate
nursing actions (expected
responses and behaviors)
42 associated with each function.
Notes
Clinical judgment functions
Function 1: Recognize cues (assessment)

Definition: The filtering of information from different sources
(i.e., signs, symptoms, health history, environment)
EXPECTED RESPONSES
AND BEHAVIORS
• Identify relevant information related

to the client’s condition.
• Use knowledge, experience, and
evidence to assess clients.
• Use verbal, nonverbal, written, and
electronic modes of communication.
• Recognize relevant subjective/objective
client data.
• Identify subtle and apparent changes in
client condition and related factors.
44
Clinical judgment functions
Function 2: Analyze cues (analysis)

Definition: The linking of recognized cues to the client's clinical
presentation and establishing probable client needs, concerns,
and problems
EXPECTED RESPONSES
AND BEHAVIORS
• C ompare client findings to evidence- • A nalyze client needs.

based resources. • Identify potential complications.
• Analyze expected and unexpected • Identify how pathophysiology relates
findings in health data. to clinical presentation.
• Anticipate illness/injury and • Identify data that are of
wellness progression. immediate concern.
• Identify client problems and related
health alterations.
Function 3: Prioritize hypotheses (analysis)

Definition: Establishing priorities of care based on the client's
health problems (i.e., environmental factors, risk assessment,
urgency, signs/symptoms, diagnostic tests, lab values)
EXPECTED RESPONSES
AND BEHAVIORS
• O rganize client assessment

information according to changes,
patterns, and trends.
• Use standards of care and empirical
frameworks for priority setting.
• Establish and prioritize client problems/
needs based on the analysis of
information and factors.
45
Phases of clinical judgment
Function 4: Generate solutions (planning)

Definition: Identifying expected outcomes and related nursing
interventions to ensure a client’s needs are met
EXPECTED RESPONSES
AND BEHAVIORS
• Collaborate with members of the

interprofessional healthcare team to
establish client outcomes and the
plan of care.
• Collaborate with the client and care
partners to establish client outcomes and
the plan of care.
• Identify optimal client outcomes and
the plan of care.
• Identify evidence-based nursing actions
to effectively address the clinical situation
of the client’s health problem.
• Prioritize the plan of care to achieve
optimal client outcomes.
• Prioritize nursing care when caring
for multiple clients.
• Reprioritize nursing actions as the
client's condition changes.
• Modify a plan of care to assure
achievement of optimal client outcomes
when indicated.
• Determine the potential impact of
selected interventions.
46
Function 5: Take actions (implementation)

Definition: To implement appropriate interventions based
on nursing knowledge, priorities of care, and planned outcomes
to promote, maintain, or restore a client's health
EXPECTED RESPONSES
AND BEHAVIORS
• P romptly and accurately perform • Incorporate client preferences and

nursing actions based on prioritized needs when performing nursing actions.
client problems. • P rovide education to the client and/or
• Implement a plan of care in care partner(s) regarding the client's
collaboration with members of the health condition and care management.
interprofessional healthcare team. • P articipate in coordination of care with
• Implement a plan of care in collaboration the client and the healthcare team.
with the client and care partners. • M onitor the client's response to
• Accurately document client care data interventions.
and information.
47
Function 6: Evaluate outcomes (evaluation)

Definition: To evaluate a client's response to nursing interventions
and reach a nursing judgment regarding the extent to which
outcomes have been met
EXPECTED RESPONSES
AND BEHAVIORS
• R eassess the client’s condition to determine achievement

of expected outcomes.
• Evaluate efficacy of nursing actions to determine
if client outcomes were met.
• Modify client outcomes and/or nursing actions based on the
client's response and clinical findings when indicated.
• Update and revise the plan of care.
48
Notes
Strategies
to teach clinical judgment
Use NCSBN's action model template: incorporate the NCJMM

in lab & clinical settings & on standard written or computer exams.
The NCSBN created an action model template1 “to define the parts of the CJMM and expected behaviors”
that nursing students need to know and perform. Use our simplified version (below) of the NCSBN’s original
to create activities and ensure you hit all the expected behaviors mentioned in previous pages.
The activities created from this action model can help you determine where students have a solid
understanding of the clinical decision-making process and where they need improvement.
(We’ve included details from an NCSBN example to get you started in how to use the tool.)
Function of clinical judgment Conditioning factor(s) Expected behaviors

Environment cues: Recognize abnormal vs. normal
Location: ED. Parent present. Vital signs
Patient observation cues: Recognize signs and symptoms
Present age: 8-10 years. Signs/ Dehydration
symptoms of dehydration: dry mucous
membranes, cool extremities, capillary
Recognize cues refill 3-4 seconds. Lethargic.
Medical record cues:
Present/imply: Hx of diabetes. Vital signs.
Time pressure cues: Identify history of
Set time pressure to vary with onset/ Diabetes
acuity of symptoms.
Requires knowledge of pediatric Describe relationship between level
Analyze cues development, dehydration, and of blood sugar and dehydration. Use
diabetes symptoms. evidence to determine client issues.
Give vital sign monitors as resources. Prioritize dehydration. Address
Prioritize hypotheses Set time pressure to vary with vital signs. dehydration. Avoid glucose.
Requires knowledge of pediatric
developmentally appropriate approach;
Generate solutions dehydration treatment and intervention;
diabetes treatment and intervention.
Take actions Experience: Nursing intervention...
Experience: Reassess vital signs.
Administering isotonic fluid. Reassess lethargy.
Evaluate outcomes Patient observation cue:

Show client awake and talking. Imply
improvement in vital signs based on
50 actions.
Strategies to teach clinical judgment
Create learning outcomes: Make sure functions of clinical

judgment are included in unit learning outcomes.
Below, we identify one behavior for each function. But refer back to the variety
of behaviors on the previous pages for more ideas when writing objectives.
RECOGNIZE CUES GENERATE SOLUTIONS

Identify relevant information Determine the potential impact of
related to a client who is selected nursing interventions.
experiencing a specific health
alteration. TAKE ACTIONS
Monitor the client's response to
ANALYZE CUES interventions.
Identify how pathophysiology
relates to the client experiencing EVALUATE OUTCOMES
a specific health alteration. Evaluate the effectiveness of the plan
of care based on the client's response.
PRIORITIZE HYPOTHESES
Organize client assessment
information according to
changes, patterns, and trends.
51
Notes
Strategies
to use in the classroom
Activity: Collecting cues

CLIENT EXAMPLE
Present students with a simulated,
written, or on-screen scenario. History and physical
• 8
5-year-old male is hospitalized for treatment
Ask students to identify the following of pneumonia.
in the scenario: • Medical history of COPD.
• Smokes ½ pack cigarettes/day.
RECOGNIZE CUES:
• Identify relevant information related
to the client’s condition. Nurses’ notes
• R ecognize relevant subjective/ • C
lient has labored breathing and is reporting
objective client data. shortness of breath.
• Lung sounds include crackles in the bases.
ANALYZE CUES • Client has a productive cough with green sputum.
• Identify how pathophysiology
• Oxygen saturation 89% on room air.
relates to clinical presentation.
• Heart sounds S1S2.
• Identify data that is of immediate
concern. • Abdomen soft, nontender.
• Reports chest pain 6/10 on a 0-10 scale.
Vital signs
• Temperature: 101.2 F (38.4 C)
• Respiratory rate: 26/min.
• Heart rate: 89/min.
• B/P: 142/84 mmHg
53
Strategies to use in the classroom
Activity: Problem identification CLIENT EXAMPLE
History and physical

Create group activity:
• 74-year-old female
• 5 ft., 8 in.
• Present students with a written or
• 175 lbs.
on-screen scenario.
• Penicillin allergy
• Give each student a sheet of adhesive dots in
• Myocardial infarction 5 years ago
multiple colors (four or five colors needed).
• Use a whiteboard to record student responses.
Nurses’ notes
• Instruct students to identify important data
• Crackles bilaterally in lung bases
from the scenario.
• Last BM 3 days ago
• As students share information, write it on
• O2 4L per nasal canula
the board.
• O2 sat 89%
• Identify data as "supportive" or "critical"
• Reports 6/10 back pain
information and underline critical information.
• 3+ pedal edema
• Invite students to go to the whiteboard and
• Ejection fraction 32%
use their colored dots to indicate associated
• Decreased appetite
information (e.g., shortness of breath; O2 at 4L
• Reports shortness of breath
per nasal canula; O2 sat 90%).
• Last BM yesterday morning
• Identify data with multiple dots and discuss the
• Denies weight change
associated client problem.
Vital signs
• Temperature: 98.8 F (37.1 C)
• BP: 154/88 mmHg
Medication administration record

(MAR)
• Lasix 40 mg daily
• Potassium 20 mEq PO daily
• Metroprolol 50 mg PO BID
• Albuterol breathing treatment q 6 hr.
• Oxycodone 5 mg PO q 6 hr.
54
Tree of impact
Activity: Tree of impact EXAMPLE
What impact does the closing of a

Organize ideas/actions and subsequent healthcare clinic have on a community?
consequences over time.
Include the following concepts:
Assign students to identify: • Healthcare quality
• Potential consequences (tree roots) • Healthcare economics
• Interventions/responses (tree branches). • Healthcare policy
• Health promotion (individual, family,
community/population, environment).
Potential client problems

and needs
55
Notes
Strategies
to use in the lab/simulation
Activity: Health assessment
• Develop a scenario (simulation, written, or on-screen) with

unexpected health assessment findings.
• Provide client information.
• Instruct students to do the following:
• Identify relevant assessment findings.
• Create a list of additional information to collect from client.
• Identify the client's priority problem.
• Identify priority intervention based on findings.
• Identify desired client outcomes.
• Document findings in the electronic health record.
CLIENT EXAMPLE

• 82-year-old seen in ED with a temperature >101 F (>38.3 C) (oral)
• Abdominal cramps and diarrhea x 4 days
• Medical history of hypertension for 20 years
• Prostrate cancer 5 years ago
Nurses’ notes
• Skin warm and dry with tenting
• Care partner says client has become confused and has not urinated for 8 hours
• Reports abdominal pain 8/10, nausea and vomiting x 3
• Reports drinking approximately 5 glasses of water with no food yesterday
• Dry mucus membranes
• Decreased urine output (amber color)
• Lung sounds clear bilaterally
• Heart sounds S1S2
• Bowel sounds hyperactive in all 4 quadrants.
Vital signs
• Temperature: 101 F (38.3 C) (oral)
• B/P: 114/66 mmHg
57
Strategies
to use in clinical
Activity: Change-of-shift report
reate an end-of-shift report that

C Repeat the activity using a different priority-
incorporates information related to the setting framework and compare:
steps of the Nursing Process. • Priority problems/needs
• Recognize cues (assessment): • Priority nursing actions
Summarize important information from • Client response to nursing actions.
the change-of-shift report.
• Generate hypotheses (analysis): Identify DISCUSSION
client problems/needs. 1) Identify client problems.
• Planning (judge hypotheses): Select a 2) Select a priority setting framework and
priority-setting framework and prioritize the prioritize the client problems/needs.
client problems/needs. 3) Identify priority nursing actions.
• Implementing (take action): Identify priority 4) Recognize client response to nursing actions.
nursing actions.
• Evaluate outcomes (evaluation): See client example on next page.
Recognize client response to
nursing actions.
58
Strategies
to use in clinical/simulation
Activity: Clinical judgment case study

Review the client example below and then follow these steps:
1) Recognize cues (assessment): Identify subjective and objective assessment information related to the
client’s condition and place it in the “Assessment findings” box.
2) A nalyze cues (analysis); Prioritize hyphotheses (analysis): Based on assessment data identify, and
prioritize the top three client problems. Write one client problem in each of the “Client problem” boxes.
3) B elow each “Client problem,” enter the “Supporting assessment” information.
4) Generate solutions (planning): Identify a potential client outcome per client problem and enter it in the
“Potential client outcomes” box.
5) T ake actions (implementation): Identify important nursing interventions that should be taken to address
each client problem and enter them in the related “Interventions” box for the associated client problem.
CLIENT EXAMPLE
• Client reports fatigue and blurry vision
• Age: 69
• Oxygen saturation: 95% on room air
• Weight: 89 kg
• Serum glucose: 835
• Admitted Dx: Hyperglycemia
• BNP: 32
• Upon admission, family reported the client
• Na+: 148
had been sick for 3 days experiencing
• K+: 4.7
nausea, vomiting, and fever of 102 F (oral)
• PMH: +Nicotine use; DM II; CAD; HTN;
Vital signs
Hypercholesterolemia; Neuropathy bilat LE.
• Temperature: 102.1 F (94.4 C) (oral)
Nurses’ notes
• Client was confused AOx2
• B/P: 172/98 mmHg
• Turgor-tenting was present; started on an
insulin drip that discontinued 4 hours ago
and started on regular NPH insulin
• Takes metformin at home for diabetes
• Heart sounds: S1S2
• Lung sounds: Expiratory wheezing
• Bowel sounds: Active in all 4 quadrants
• Client reports a headache with a
pain level of 8/10
• Client reports excessive thirst and urination
59
Assessment findings: Client problem 2: Add supporting
assessment information
Interventions:
Client problem 1: Add supporting Client problem 2: Add supporting

assessment information assessment information
Interventions: Interventions:
Potential client outcomes
1.
2.
3.
60
Clinical judgment case study activity (continued)
QUESTIONS
• What additional factors should the nurse • Based on the performed nursing
include in the plan of care for this client? interventions, what client outcomes
(Generate solutions; Planning) would you anticipate?
(Generate solutions, Planning)
º For
example: age, religious,
nursing knowledge, literacy, • How will you determine if expected
or cultural preferences. client outcomes are achieved?
(Evaluate outcomes; Evaluation)
• What safety considerations should be
included when planning care for this client? • Discuss ways to modify or revise the plan
(Generate solutions; Planning) of care when client outcomes are not met.
(Evaluate outcomes; Evaluation)
º For
example: fall risk, medication,
age, mobility.
• What education should the nurse

provide to this client?
(Take actions; Implementation)
º Self-care,
health promotion, disease
management (for example, medication,
diet, activity, ADLs)
61
Strategies
to use in clinical/simulation
Activity: Clinical and simulation strategy journal

Use the guidelines below for a journal assignment following a clinical experience.
• Client information
Recognize cues • Focused assessment
• Medications, lab, and diagnostic tests
• Identify expected/unexpected findings

Analyze cues • Identify potential complications
• Identify data of immediate concern
Prioritize • Organize assessment data according

to client changes and trends
hypotheses • Prioritize client problems/needs
Generate • Collaborate with client, care partner,

and interprofessional team to establish
solutions outcomes and plan of care
• Perform nursing actions based on prioritized problems

Take actions • Accurately document client care data
• Monitor client’s response to interventions
• Reassess client condition to determine

achievement of expected outcomes
Evaluate outcomes • Modify outcomes and/or nursing actions
based on client’s response
Details
about the new exam
The Next Gen NCLEX will cover more than

just clinical judgment.
When you read or hear about the and the clinical judgment to care for
NGN, the emphasis is typically on the clients safely and effectively.
measurement of clinical judgment,
because that’s what’s changing. Remind students that the new test is
not designed to trick them or measure
But the NGN won’t focus solely on whether they are master nurses. Its
assessing clinical judgment. It will purpose is to better evaluate each
continue to include items that require candidate's clinical judgment ability rather
the application of knowledge. than simply measure nursing knowledge.
Assessing knowledge continues to be For a minimum-length test, students will

important. After all, clinical judgment — see about 25 percent NGN items, and
in and of itself — is not nursing; nursing is for a maximum-length test, they will see
a combination of having the knowledge about 19 percent NGN items.
25% 19%
For a minimum-length For a maximum-length

test, students will see test, students will see
63
about 25% NGN items. about 19% NGN items.
The length
of the Next Gen NCLEX
The length of the new exam will be slightly different
than the current NCLEX.
The NGN will present 70-135 scored items KNOWLEDGE

(plus 15 pretest items) based on the test-taker's Every candidate also will answer a
ability. The unscored items will not contribute minimum of 52 knowledge-focused
to the candidate’s test score but will be used items.
for future exam development. In all, the total
exam length will be 85-150 items. Among After answering the initial 85 items
the scored items on a minimum length test, (70 scored + 15 pretest), if a student
candidates should expect three case studies is close to the cut score (see page
with 18 of the 85 items (21%) to be NGN. 69), he or she will be asked additional
questions. Most of these will be
knowledge-based, but about six to
CASE STUDIES MEASURING
seven will focus on clinical judgment
CLINICAL JUDGMENT
in the form of stand-alone items. The
Every candidate will respond to three case
maximum number of questions, then,
studies that count toward their score. The
will be 150 (135 scored + 15 pretest).
unscored items on the test may also include
case studies or standalone NGN items, so
candidates may see more than three case
studies in total. Each case study is comprised
64 of six clinical judgment items.
Time required
to answer new item types
Students don't need a lot more time to answer items
on the new version of the exam.
Initially, the NCSBN theorized that The lower time required is likely due
graduates would spend double the to students "carrying knowledge"
time answering an NGN-style item from one case study question to
compared to a standard NCLEX item. the next, continually gathering
It turned out that expectation information as the case study unfolds.
was incorrect. As a result, they can answer items
more quickly.
Instead, candidates are taking only
about 15 seconds more to answer an
NGN item compared to a regular item
65 on the current NCLEX.
Reminders
about the NCLEX
Refresh your memory on some important aspects

of the exam that won't be changing.
COMPUTER ADAPTIVE TESTING (CAT) THE CUT SCORE

This method of administering both the NCLEX This is the "cut point" along
and the NGN combines computer technology an ability range that marks the
with measurement theory to conduct exams minimum aptitude required to safely
more efficiently. and effectively practice nursing at
• When an item is answered, the the entry-level. Because both the
computer re-estimates the candidate's current NCLEX and the NGN are
ability based on each individual item computer-adaptive, the computer
and the difficulty of those items. stops administering items when it is
• The computer selects the next item the 95 percent certain the candidate's
candidate should have a 50 percent chance ability is either clearly above or
of answering correctly. clearly below the passing standard.
• The computer's estimate of the
candidate's ability becomes more precise ACCOMMODATIONS
as more items are answered. The future NCLEX will offer the
• When the computer establishes the same accommodations offered
candidate's ability, after the minimum items today. For example, a paper-pencil
have been answered, the examination ends. accommodation would be denied
because the test is adaptive. But a
• N
ote: Items within case studies are not
candidate can request extra time, a
computer adaptive.
separate room, reader, or recorder.
For the visually impaired, JAWS
software will be used. (Students
should request accommodations from
their state-specific regulatory body.)
66
Differences between
the current NCLEX & the NGN
What won't change from the current NCLEX.
BASIC FACTORS MAJORITY OF ITEM TYPES

• The exam will continue to measure the same Dr. Dickison cleared up a
critical content areas. misconception for many that the
• Most items on the entire exam revised exam will focus exclusively on
will be standard NCLEX items. new NGN-style item types.
• The scoring scale will not change.
• The exam will remain computer-adaptive. “The majority of items on a minimum-
length exam will still be the standard
We asked the NCSBN's Dr. Dickison to NCLEX item types,” he said.
provide more detail on the factors above:
SAME SCORING SCALE
CONTENT AREAS COVERED "We’ve kept that scale stable for
The reason for changing the NCLEX was to 20 years,” Dr. Dickison said. Going
measure clinical judgment, but the exam’s forward from the NGN he noted,
focus won't change in terms of the overall the exam will continue to offer
content it covers. longitudinal comparisons of nurse
ability; scores will be comparable
“Just because we’re measuring clinical from four years ago to a year after the
judgment doesn’t mean all the other stuff that NGN launches.
we’ve been measuring is not important; it’s
still important,” Dr. Dickison explained.
67
Differences between the current NCLEX & the NGN
What will change from the current NCLEX.
BASIC FACTORS STAND-ALONE ITEMS

• Each candidate will see new item types. Two stand-alone item types will be
• Students will be presented with case-study offered: the bow-tie and the trend.
items and stand-alone items. Candidates who continue beyond the
• Some items on the test will use minimum-length exam may receive
partial-credit scoring (dichotomous and as many as six to seven of these item
polytomous). types on the rest of their exam.
NEXT GENERATION NCLEX ITEMS PARTIAL-CREDIT SCORING

The Next Gen NCLEX will then measure The NCSBN's Dr. Dickison said some
clinical judgment in two different ways: new item types on the NGN won’t
be scored as simply right or wrong.
1) C
ase study items that reflect real- Instead, candidates will receive full,
world clinical situations and the decisions partial, or no credit for an answer
nurses make to address clients' needs and based on the selected response.
anticipated outcomes. (See page 86.)
2) S
tand-alone items that are not part of
a case study.
CASE STUDY ITEMS

Case study items require candidates
to respond to items representing each
function of clinical judgment in order:
recognize cues, analyze cues, prioritize
hypotheses, generate solutions, take
actions, and evaluate outcomes.
68
New item types on the NGN
The most significant change to the test will be
unique new item types
The NCSBN researched a variety of item types to determine which best measure clinical
judgment. The organization settled on 12 for use with case studies and two for the use of
stand-alone items. (A standard multiple-choice item can also be used in a case study.)
WHAT ARE THE NEW ITEM TYPES? WHAT ARE STAND-ALONE

• Matrix multiple-choice ITEM TYPES?
• Matrix multiple-response They are broken into two types:
• Multiple-response: Select all that apply • Bow-tie: Incorporates all six
• Multiple-response: Select N functions of clinical judgment
• Multiple-response: Grouping in one item.
• Drag-and-drop: Cloze • Trend: May use any one of the
• Drag-and-drop: Rationale NGN item types; includes data
• Drop-down: Cloze that trend over time; target one
• Drop-down: Rationale or more of the six Layer 3 clinical
• Drop-down: Table judgment functions.
• Highlight: Text
• Highlight: Table.
WHAT IS A CASE STUDY ITEM TYPE?

• May use a variety of NGN item types
• Consists of six items
• Includes one item for each of the six
functions of clinical judgment (recognize
cues, analyze cues, prioritize hypotheses,
generate solutions, take actions, and
evaluate outcomes) in Layer 3 of the NCJMM.
69
An introduction
to the case study
Case studies are an effective way to measure

clinical judgment.
Case studies are real-world 1) Recognize cues. (What matters most?)

nursing scenarios that focus 2) Analyze cues. (What does it mean?)
on the six clinical judgment 3) Prioritize hypotheses. (Where do I start?)
functions of Layer 3 of the Clinical 4) Generate solutions. (What can I do?)
Judgment Measurement Model. 5) Take actions. (What will I do?)
6) Evaluate outcomes. (Did it help?)
TIP: To simplify these functions
for students, define them using
the questions in parentheses:

What matters What does Where do I start? What can I do? What will I do? Did it help?
most? it mean?
70
The format of case studies
Case studies are displayed on a split-screen format
LEFT SIDE RIGHT SIDE

Describes the scenario and includes a rendition Includes the questions to be
of a client-care record with tabs for nursing notes, answered. These questions will
laboratory results, provider orders, vital signs, and be in the form of new item types
history and physical. specially designed to assess
clinical judgment.
Tabs are offered throughout the case study and may
include additional information as the case progresses
— just like in real life, where a client’s condition
changes or more information becomes available.
Nurses’ notes
1000: Client was brought to the ED by her daughter due to

Select the 4 findings that require
increased shortness of breath this morning. The daughter reports
immediate follow-up:
that the client has been running a fever for the past few days and
has started to cough up greenish-colored mucous and reports
vital signs
"soreness" throughout her body. The client was recently hospitalized
for issues with atrial fibrillation 6 days ago. The client has a history of lung sounds
hypertension. Vital signs: T 101.1 F (38.4 C), heart rate 92/min.,
capillary refill
respiratory rate 22/min., BP 152/86 mmHg, pulse oximetry reading
94% on oxygen at 2 L/min. via nasal cannula. Upon assessment, the client orientation
client's breathing appears slightly labored, and course crackles are
radial pulse characteristics
noted in bilateral lung bases. Skin slightly cool to touch and pale in
tone; pulse +3 and irregular. Capillary refill is 3 seconds. Client is characteristics of the cough
alert and oriented to person, place, and time. The client's daughter
states, "Sometimes it seems like my mother is confused."
71
Case study format
Once the candidate answers an item, the (See the red arrow pointing to the new note added at
screen will update and present a new item noon. Note: The red arrow will not appear for students.
on the right. It is shown here for illustrative purposes only.)
The client information on the left side may Items within a case study are static and are not
remain the same, or new information may be computer-adaptive. But the NCSBN has indicated that
added, such as in the close-up view of there will be an estimate at the end of each case study.
nurses’ notes below.
Nurses’ notes
1000: Client was brought to the ED by her daughter due to increased shortness of
breath this morning. The daughter reports that the client has been running a fever for
the past few days and has started to cough up greenish-colored mucous and to report
"soreness" throughout her body. The client was hospitalized for issues with atrial
fibrillation 6 days ago. The client has a history of hypertension. Vital signs: temperature
101.1 F (38.4 C), heart rate 92/min., respiratory rate 22/min., B/P 152/86 mmHg, pulse
oximetry reading 94% on oxygen at 2 L/min. via nasal cannula. Upon assessment, the
client's breathing appears slightly labored, and course crackles are noted in bilateral
lung bases. Skin slightly cool to touch and pale in tone; pulse +3 and irregular. Capillary
refill is 3 seconds. Client is alert and oriented to person, place, and time. The client's
daughter states, "Sometimes it seems like my mother is confused."
1200: Called to bedside by the daughter who states that her mother "isn't acting right."
Upon assessment, client is difficult to arouse, pale, and diaphoretic in appearance. Vital
signs: temperature 101.5 F (38.6 C), heart rate 112/min., respiratory rate 32/min., B/P
90/62 mmHg, pulse oximetry reading 91% on oxygen at 2 L/min. via nasal cannula.
72
An introduction
to stand-alone items
These item types also will assess clinical judgment.
Stand-alone items are individual questions that are NOTE: Candidates who answer
not part of a case study but have a similar format. more than the minimum number
They are introduced after the minimum number of items will be presented with
of items. additional questions of which
about six to seven will be NGN
Stand-alone items target one or more of the clinical stand-alone items.
judgment functions in Layer 3 of the NCJMM.
Stand-alone items will consist of two item types:
A BOW-TIE ITEM TREND ITEM

Bow-tie items address all six steps of the Trend items are individual items in a
NCJMM in one item. The candidate reads scenario in which the candidate reviews
a scenario to recognize whether findings information in the medical record that
are normal or abnormal (recognize cues), trends over time (from minutes to hours,
understands the possible complications days, or more). Trend items address one
or medical conditions the client may be to all of Layer 3 of the NCJMM. Trend
experiencing (analyze cues), and identifies items can feature any item response type.
possible solutions to address the client’s Possible tabs include “Nurses’ notes,”
needs and issues (generate solutions). “History and physical,” “Laboratory
The candidate then answers the question results,” “Vital signs,” “Admission notes,”
to determine the most likely cause of the “Intake and output,” “Progress notes,”
client’s issues (prioritize hypotheses), the “Medications,” “Diagnostic results,”
appropriate actions to take (take action), and and “Flow sheet.”
the parameters to monitor once interventions
have been implemented (evaluate outcomes).
73
Sample of a bow-tie stand-alone item
The nurse is reviewing the client’s assessment data
to prepare the client’s plan of care.
> Complete the diagram by dragging from the choices below to

specify what condition the client is most likely experiencing, two
actions the nurse should take to address the condition, and two
parameters the nurse should monitor to assess the client’s progress.
Action to take Parameters to monitor
Condition most
likely experiencing
Action to take Parameters to monitor
Potential
Actions to take conditions Parameters to monitor
Request a prescription
Bell's palsy temperature
for an oral steroid.
Administer oxygen at 2
hypoglycemia urinary output
L/min via nasal cannula.
Insert a peripheral venous

ischemic stroke neurologic status
access device (VAD).
Obtain a urine sample for

urinalysis and culture and urinary tract infection (UTI) serum glucose level
sensitivity (C&S).
Request an order for 50%

electrocardiogram
dextrose in water to be
(ECG) rhythm
administered intravenously.
74
The different formats
of case study and trend item types
75
Case study item types
The matrix item type: multiple-choice & multiple-response
A matrix item type is presented A matrix multiple-response will have four to

in a table-like format. seven rows and two to 10 columns. Each column
must have at least one response. A row can have
A matrix multiple-choice item zero to all answers.
will have four to 10 rows and two
to three columns. Each row must A clue as to how many answers candidates can or
have only one answer. should choose? Look at whether the grid contains
circles or boxes. Circles (also known as radio buttons)
only allow candidates to choose one option.
Matrix multiple-response example

Bowel Ruptured
Assessment finding Appendicitis
obstruction spleen
Appetite
Pain level
Bowel pattern
Gastrointestinal symptoms
Matrix multiple-choice example

Assessment finding Improved No change Declined
RR 36
BP 118/68
Pale skin tone
Pulse oximetry reading 91%
Interacting with daughter at bedside
76
Case study and trend item types
The highlight item type: text & table
On this item type, candidates are medication record) and then select the words
instructed to “click to highlight” the or phrases that answer the question.
appropriate answers to the question. The answer can also be part of a sentence.
This item type can be presented in a The answer options will be shown when
table format or in a chart tab where the the candidate hovers over a section that is
candidate clicks to highlight a token that tokenized. The student will then click to
answers the question. Candidates read a choose it as an answer.
portion of a client medical record (e.g., a
nursing note, medical history, lab values,
Example
Example
of a of
highlight
a highlight
itemitem
text text Example
Example
of a of
highlight
a highlight
itemitem
tabletable
Click to
Click
highlight
to highlight
the findings
the findings
belowbelow
that would
that would Click to
Click
highlight
to highlight
belowbelow
the findings
the findings
that that
indicate
indicate
the client
the client
is not isprogressing
not progressing
as expected.
as expected. require immediate
require immediate
follow-up.
follow-up.
History
History
and physical
and physical
Progress
Progress
notes notes
Client isClient
post-op
is post-op
day #3 day
after#3splenectomy
after splenectomy
and is able
and is
toable to
Body system Findings
ambulate
ambulate
in the corridor
in the corridor
3 to 4 times
3 to 4daily
timeswith
daily
minimal
with minimal
pupils equal
pupils
andequal
reactive
andto
reactive
light and
to light
accommodation;
and accommodation;
assistance.
assistance.
The client
Thehas
client
clear
hasbreath
clear breath
soundssounds
with a left
withchest
a left chest Neurological
Neurological anterior and
anterior
posterior
and posterior
fontanel sunken;
fontanelmoves
sunken;
allmoves all
extremities
extremities
weakly weakly
tube intube
placeinattached
place attached
to a closed-chest
to a closed-chest
drainage
drainage
system.system.
crackles (rales)
crackles
noted
(rales)
in bilateral
noted in bases
bilateral
uponbases upon
TidalingTidaling
of the water
of thechamber
water chamber
noted with
noteddeep
withinspiration.
deep inspiration. Pulmonary
Pulmonary auscultation;
auscultation;
mild grunting
mild grunting
and headandbobbing;
head bobbing;
tachypneictachypneic
The client
Theisclient
refusing
is refusing
to use the
to use
incentive
the incentive
spirometer
spirometer
statingstating
it it
pulses 2+pulses
in all extremities;
2+ in all extremities;
capillary refill
capillary
3 seconds;
refill 3 seconds;
causes causes
left-sided
left-sided
chest pain.
chestThe
pain.
client
Theisclient
utilizing
is utilizing
prescribed
prescribed Cardiovascular
Cardiovascularhands andhands
feet slightly
and feetcool
slightly
to touch;
cool to
mediastinal
touch; mediastinal
chest tube
chest
in place,
tube serosanguineous
in place, serosanguineous
drainage drainage
noted noted
patient-controlled
patient-controlled
analgesia
analgesia
(PCA) device
(PCA) device
maximally
maximally
every every
hour and
hour
continues
and continues
to havetointermittent
have intermittent
nauseanausea
with some
with some Gastrointestinal
Gastrointestinal
hypoactive
hypoactive
bowel sounds;
bowelabdomen
sounds; abdomen
soft and round
soft and round
vomiting.
vomiting.
Adequate
Adequate
urine output.
urine output.
Abdominal
Abdominal
surgicalsurgical
incisionincision
site with
site
dressing
with dressing
is clean,is dry,
clean,
and
dry,
intact
andwith
intact
nowith
erythema,
no erythema,
edema,edema,
or drainage
or drainage
noted to
noted
site.to site.
77
Case study and trend item types
The drag-and-drop item type: rationale & cloze
On drag-and-drop item types, the candidate will drag word choices

(options) from the word choice box to the targets in the question.
DRAG-AND-DROP CLOZE DRAG-AND-DROP RATIONALE

• Presents information in • Presents information in a single sentence
sentence format • The sentence contains two targets
• Contains one to five answer (dyad) or three targets (triad)
spaces, or targets, that represent • Answers are selected from
a missing word or short phrase corresponding word boxes and dragged
• Answers are dragged from word- to appropriate targets
choice box to targets • This item type will have two word-choice
• The word-choice box contains boxes with five options each.
four to 10 word choices
• The word-choice box always
includes more word choices
than available targets
Example of a drag-and-drop rationale Example of a drag-and-drop cloze E
Drag words from the choices below to fill in Drag 1 condition and 1 client finding to fill in Dr
each blank in the following sentence. each blank in the following sentence. ea
due to The client is at risk for developing , The client is at risk for developing due to The c
, and
Word choices Condition Client findings Wor
infection bedrest
wound dehiscence wou
contractures chest tube placement

infection infe
dysrhythmias wound approximation

pleural effusion pleu
pleural effusion respiratory assessment findings

dysrhythmias dys
wound dehiscence purulent drainage from incision site

contractures con
seizures seiz
78
The multiple-response item type: select all that

apply, select “N,” & grouping
MULTIPLE-RESPONSE SELECT MULTIPLE-RESPONSE SELECT “N”

ALL THAT APPLY Presents information in a sentence format with a
In this item type, there are five to 10 list of five to 10 options. The number of correct
options. Select one to all options to answers is indicated in the stem of the item.
answer the item. (See example below.) Candidates select the appropriate number of
options to answer the item.
Example of multiple-response MULTIPLE-RESPONSE GROUPING

Example of multiple-response
select all that apply Presents informationselectin"N" item format with
a sentence
two to five small groups of options. Each group
contains two to four options with one to four
The nurse has been asked to prepare the patient for
correct answers. Select one to all options in each
Selectto
group 4 answer
findings that immediate
requireThe
the item. numberfollow-up.
of correct
immediate surgery. Which of the following actions
should the nurse take? Select all that apply. answers
vital in each group might not be the same.
signs
Mark the surgical site. lung sounds
Provide the client with ice chips. NOTE: See refill
capillary page 86 for scoring on this item type.
Obtain surgical consent from the client. client orientation
Perform a medication reconciliation.
Example ofcharacteristic
radial pulse a multiple-response grouping
Insert a peripheral venous access device (VAD). characteristics of the cough
Inform the client about the risks and benefits of the surgery.
Example
Assessof
theaclient’s
drop-down rationale
previous experience with
For each body system below, click to specify the potential
surgery and anesthesia.
nursing intervention that would be appropriate for the care
Ask the client’s parents to wait in the waiting room while
of the client. Each body system may support more than 1
you discuss the plan of care with the client.
potential nursing intervention.
Body system Potential nursing interventions

Complete the following sentence by choosing from
Example of multiple-response
the list of options Neurologic neurologic check every 2 hours
select "N" item
computed tomography (CT) scan
The client is at highest risk for developing Select morphine 1 mg, IV, every hour p.r.n. pain
as evidenced by the client’s Select... electroencephalogram (EEG)
or hypoxia
Select Select 4 findings that require immediate follow-up. Cardiovascular chest x-ray every morning
stroke
Select... oxygen at 2 L/min. via nasal cannula
vital signs dysrhyhmias
vital signs a pulmonary embolism arterial blood gas (ABG) every 4 hours
lung sounds
neurologic assessment incentive spirometry every 1 hour
respiratory assessment
capillary refill
Respiratory aspirin 81 mg, p.o., every morning
cardiovascular assessment
client orientation
echocardiogram
radial pulse characteristic continuous telemetry
characteristics of the cough defibrillator at bedside

gery.
79
e
The drop-down item type: cloze, rationale, & table
DROP-DOWN CLOZE DROP-DOWN TABLE

• Presents information in sentence format. • Presents information in a table containing at
• Contains two to five drop downs that least one column and three rows.
represent missing information in the form • Each row has one drop down that the
of a word or short phrase; each drop candidate must answer.
down has three to five options, and the • The candidate selects an option from each
candidate selects an option from each drop down.
drop down to complete the sentence.
DROP-DOWN RATIONALE
• Presents information as a single
sentence containing two drop downs Example of a drop-down cloze
(dyad) or three drop downs (triad) that
represent missing information in the
form of a word or short phrase. The
candidate selects the option from each Complete the following sentence by Fo
using the list of options nu
drop down to complete the sentence. th
po
The nurse should first address the client’s Select
followed by the client’s Select Abdominal pain

Bod
Respiratory status
Laboratory test results Neu
Res
Car
Example
Example of
of aa drop-down
drop-down cloze
rationale Example of a drop-down table
Complete
Complete thethe
following sentence
following by by choosing from
sentence For each body system below, click to specify the potential
using
thethe
list list of options
of options nursing intervention that would be appropriate for the care of
the client. Each body system may support more than 1
potential nursing intervention.
TheThe
nurse should
client is atfirst address
highest client’s Select
the developing
risk for Select
followed by the client’s
as evidenced Select
by the client’s Select...pain
Abdominal
hypoxiastatus
Respiratory
Select
stroke Neurologic Select
Laboratory test results
Select... dysrhyhmias
vital signs a pulmonary embolism Respiratory Select
neurologic assessment
respiratory assessment
Cardiovascular Select
cardiovascular assessment
80
Notes
Differences in scoring
the Next Generation NCLEX
How new item types will be scored
With traditional NCLEX items, answers are either NOTE: Standard items
right or wrong. Responses may receive zero or one (Fill-in-the-blank numeric,
point. This is referred to as dichotomous scoring. Multiple choice, Multiple-
response select all that apply,
For NGN-style items, the NCSBN decided to Hot spot, and Ordered
add two different scoring methods to allow for response) continue to
partial credit. be worth one point. (The
Multiple-choice item can
All of the new items will be correct or incorrect. be text or a graphic. In 2023,
Some will have partial scoring to give a candidate Multiple-response items will
partial credit. This is referred to as polytomous receive partial scoring.)
scoring.
Partial credit scoring can be assigned in

different ways:
• +/- scoring: Candidates earn one point for each
correct response and lose one point for each
incorrect response. Scores are summed together
to get the item total score. If the summed value is
negative, the final score will be truncated to zero.
• 0/1 scoring: Candidates earn one point for each
correct response and points are not deleted
for incorrect responses. Points are summed
together to get the item total score.
• Rationale scoring: In a dyad, candidates earn
one point when both responses in a paired set
are answered correctly. In a triad, candidates get
one point if they get the cause and one effect
correct. The candidate gets two points if they
get all correct.
82
Developing & assessing
clinical judgment skills
The art and science behind assessments
ATI relies on a scientific approach We rely on a team of experts with decades of

to develop and maintain the experience in five key disciplines:
highest-quality assessments. We
apply four basic processes:
RESEARCH & PSYCHOMETRICS
Master’s- and PhD-level experts who ensure
1) A
pplying scientific principles
the science behind ATI assessments.
and research to create rigorous
and trustworthy products CONTENT DEVELOPMENT
and solutions Master’s- and doctorate-prepared nurses
2) Instituting processes that with years of content-specific experience and
meet or exceed testing- teaching who have mastered item writing and a
industry, publishing, and strong network of diverse external experts who
ethical standards for develop creative and original content.
product and assessment
development ASSESSMENT & LEARNING PRODUCTS
3) Insisting on exceptional Test developers, editors, and designers who
caliber originality, accuracy, create products and assessments that meet an
and consistency array of specifications.
4) Setting rigorous expectations MEDIA DEVELOPMENT
that ensure legal defensibility Skilled professionals who engage every type
of products and accreditation of learner with thoughtful applications using
status. a variety of innovative media tools that allow
access to those with disabilities.
NOTE: During the National
Simulation Study (2014), the TEST SECURITY
NCSBN selected ATI ’s Content Experts who actively protect the validity and
Mastery Series® exams as their intellectual property of our products through
measurement tool for student preventive and correction efforts.
nursing knowledge.
83
The ATI process of item development
T E S T B LUEPR I N T JOB TASK AN A LYSIS

Item writing
Score reporting Item review
Equating and/or
scaling Pretesting
Validity
Statistical analysis Statistical analysis
and review and review
Test assembly
Live testing
Standard setting
An overview: Assessment development
ATI maintains a rigorous process to establish and support

the reliability, validity, and trustworthiness of its assessments.
Establishing the validity of an assessment requires an ongoing
collection of procedural and empirical evidence throughout the
life of the product. It starts early, and it continues throughout the
ATI Assessment Development Process:
• Test-plan development
• Item-level development
• Test-level development
• Test maintenance
• Outcomes assessment.
84
Item development is a meticulous process. Three key steps align job analysis and the NCLEX
It consists of: test blueprint for both the NCSBN and ATI:
CONTINUOUS ITEM DEVELOPMENT THE NCSBN

The steps involved include: • P erforms a Job Analysis Study every
• A strong network of diverse internal and three years
external content experts • Develops the NCLEX-RN and NCLEX-PN
• Content experts who consistently apply test plans
evidence-based practices to ensure content is • Researches aspects of nursing to aid in
valid and defensible improved client care, such as the range and
• ATI item-writing guidelines that mirror NCLEX number of tasks expected of entry-level nurses.
style of items.
ATI NURSING EDUCATION
• Conducts
a Test-Plan Development
ITEM REVIEW MEETINGS CONDUCTED BY Meeting as needed.
TEST DEVELOPERS AND EXPERIENCED • Performs a crosswalk of the new NCSBN test
NURSE EDUCATORS plan and adjusts our current test plans to align.
These meetings include: • Finalizes the ATI test plan.
• A review of each item by two content experts
• An analysis that ensures all content is relevant
and tied to a blueprint task
• Confirmation that all items meet the item-
writing guidelines
• A determination whether proctored items are
ready for pretesting
• A final review of items that didn’t fall into the
statistical range originally set for them.
85
Testing & equating
Is your test harder than mine? Why equating is important.
• T otal scores are adjusted between Pretest items, however, do not

different assessment versions to contribute to a candidate’s
compensate for (small) differences score. Candidates are not able to
in difficulty. differentiate between operational
• Most ATI proctored assessments and pretest items.
are equated, meaning that different
versions of the assessment This process allows ATI to collect
and their scores can be used high-quality administration
interchangeably. data. Once we have this data,
we examine the items for their
After an item is approved, it will psychometric performance. For
then be pretested to ensure it is example, we review their difficulty
psychometrically sound. and their ability to discriminate
between high-performing and low-
Assessments are often comprised of performing candidates.
both operational items (scored) and
pretest items (unscored). Operational Items that don’t perform well are
items have already completed the full reviewed and potentially revised.
development process, are known to
perform to an acceptable standard,
and are used to determine the
candidate’s score on the assessment.
86
Test security
for proactive protection
ATI employs a variety of technical controls and test designs
EMBEDDED CONTROLS PROPRIETARY TECHNOLOGY FOR

Built within proctored assessments, this DETECTING IP (INTELLECTUAL
preventive measure alerts the proctor PROPERTY)
if a candidate attempts to navigate This technology mitigates risk associated with
away from the assessment, which content theft and assists in easier identification
could indicate exam misconduct or of ATI content with quick determination
compromise of exam items. whether the content has been compromised.
APPLICATION SECURITY REVIEWS ENHANCED ASSESSMENT

Web application security reviews DISTRIBUTION
identify security risks associated with ATI randomly distributes a set of items
high-severity vulnerabilities found by an nationwide to decrease item exposure and
independent third-party (professional lessen predictability.
hacker) in our environment.
86
87 86
87
Clinical judgment tools
for development & assessment
For years, ATI has focused on improving students’ clinical

judgment skills, evaluating new item types, exploring scoring
methods, and developing new items.
Tools for development

REAL LIFE CLINICAL REASONING SCENARIOS
Screen-based simulation to encourage critical thinking, clinical decision-making,
and clinical judgment with deep engagement in realistic client scenarios. Using
branching logic, students are challenged to make important healthcare decisions
as they progress through each scenario, significantly impacting client outcomes.
NURSE’S TOUCH SUITE

With six active-learning solutions, students receive the crucial opportunity to build their
skills in realistic, challenging scenarios. Then, upon entering an actual clinical setting,
they’re well-versed with that special touch of a professional nurse. Media-rich tutorials,
video case studies, virtual simulations, and nationally normed NCLEX-style item assessments
boost student confidence and elevate their preparedness to a professional level.
HEALTHASSESS
In a single health assessment teaching solution, HealthAssess offers a combination of learning
modules and authentic practice simulations to fully prepare nursing students to perform health
assessments on all major body systems using the most current techniques and practices.
VIDEO CASE STUDIES

Video Case Studies offer an easier way for students to grasp difficult concepts. The scenarios,
which feature live actors, help students visualize what to expect in clinicals and then end with
a question. Students formulate their own plan of care instead of choosing from a set of options,
challenging them to flex and refine clinical judgment skills along the way.
88
NURSE LOGIC 2.0

Teaches students to “think like a nurse.” It gives a formal
introduction to critical thinking methods, the nursing
process, priority setting frameworks, and test-taking
strategy.
SKILLS MODULES 3.0

With the knowledge delivered from 30 modules —
each featuring tutorials, step-by-step demonstration
videos, checklists, quick references, animations, pre- and
post-tests, challenge cases, remediation, and more —
students will enter the on-site skills lab with more refined
clinical judgment skills.
ATI ENGAGE SERIES

A 40-lesson alternative to students’ fundamentals
textbooks equips students with modules that are broken
into easy-to-digest segments of content and interwoven
with rich multimedia graphics, videos, and engaging
activities that help students apply their learning. Plus,
students find clarity in consistent skills techniques with
embedded videos from ATI’s Skills Modules and through
practice with active EHR documentation from ATI’s fully
integrated EHR Tutor.
SWIFT RIVER VIRTUAL CLINICALS

Virtual Clinicals offers a series of more than 600 screen-
based simulation scenarios covering all the major clinical
areas. Students become more prepared and confident
for the clinical setting, gaining experience through
exposure to hundreds of diverse client scenarios. They
are given the opportunity to begin making clinical
decisions, including practice with analytical thinking,
prioritization, and delegation.
Tools for assessment

THE NCLEX EXPERIENCE COMPREHENSIVE PREDICTOR –
Available for RN and PN, this product gives WITH NGN ITEMS
students an orientation and an opportunity to COMING SOON!
practice with Next Generation NCLEX item types Comprehensive Predictor is the last stop for students
in a low-stakes environment. before they enter intensive NCLEX prep. This three-
hour, 180-item, proctored test is designed to help
CONTENT MASTERY SERIES students assess their likelihood of passing the NCLEX
The Content Mastery Series is designed to while detailing areas for further remediation.
provide data related to a student’s mastery
of specific concepts related to the NCLEX. CONCEPT-BASED CURRICULUM –
Each core content area includes a proctored WITH NGN ITEMS
assessment and online practice assessment, as COMING SOON!
well as remediation materials in print and online. ATI’s standardized RN Concept-Based Assessments
are the first of their kind to provide nationally normed
CUSTOM ASSESSMENT BUILDER tests with proficiency benchmarks for use in concept-
This tool allows you to create and maintain based curricula. Forty-six different key nursing concepts
exams quickly and easily by providing you with are covered in our online practice and proctored
thousands of test items from an expansive ATI assessments, all featuring NCLEX-style questions.
item bank and giving you the ability to create At four progressive stages across a nursing program’s
your own custom items. Select individual items to curriculum, nurse educators can monitor and measure
create an assessment or design a test blueprint student mastery in each concept.
and opt for the Custom Assessment Builder to
handle item selection for you.
90
ATI tools in development + available now
ASSESSMENT FUNCTIONALITY & ENHANCEMENTS
• Writing NGN-style items. ONGOING
• A new testing engine to support NGN-item types. IN PROGRESS
• New scoring methods for NGN items. COMPLETED
• Pretesting NGN items. ONGOING
• NGN items in select Content Mastery Series assessments. AVAILABLE NOW & ONGOING
• NGN items in the Comprehensive Predictor assessment. COMING 2022
• NGN items in Custom Assessment Builder assessments. AVAILABLE NOW & ONGOING
• NGN items in Concept-Based assessments. COMING 2022
• The NCLEX Experience. IN PROGRESS
• Next Generation NCLEX Questions Overview. RECENTLY UPDATED
• Next Generation NCLEX Item Scoring Videos. IN PROGRESS
Following are the ATI Content Mastery Series assessments that will also have NGN items:
• Fundamentals • Maternal Newborn

• Mental Health • Nursing Care of Children
• Adult Medical Surgical • Comprehensive Predictor
91
Notes
How to stay up-to-date
on Next Gen NCLEX
Where can you find the most up-to-

date resources to help you prepare for
the Next Generation NCLEX (NGN)?
In the ATI Next Generation NCLEX
Resource Center1. It compiles all of the
crucial information delivered by the
NCSBN and builds on it with advice
offered by experts from throughout
the nursing profession.
• Get expert guidance on the NGN: • G et up-to-date information from

• The latest information the NCSBN:
and resources • Clinical Judgment
• Foundational information Measurement Model
about the new test. • Item types
• Learn about clinical judgment, • Search ATI’s suite of products and tools
the backbone of the NGN: to incorporate into your lessons and
• A guide to assist you in prepare students for the NGN.
developing learning materials
• How simulation can help build Talk to someone at ATI to answer
clinical judgment skills. your questions.
93
Get all your questions
answered about NGN
The development of students’ clinical judgment isn’t simply about
helping them pass the NCLEX. It’s about ensuring they are ready for
the rigors of real-life practice and providing better patient care.
What can you do today to prepare students for the new future that
NGN will introduce?
Turn to ATI‘s teaching and learning solutions to help you develop

and sharpen students’ clinical judgment skills. Whether you want
more information on the resources provided here or on ATI‘s Next
Generation NCLEX Resource Center, or if you have questions unique
to your institution, we’re ready to help.
OFFICE HOURS PHONE

6 a.m.–9 p.m. (CT) Phone: (800) 667-7531
Monday–Friday Fax: (913) 661-6245
TECHNICAL SUPPORT HOURS ADDRESS

7 a.m.–7 p.m. (CT) 11161 Overbrook Road
Monday–Friday Leawood, Kansas 66211
SEASONAL SUPPORT HOURS

8 a.m.–noon (CT)
Saturdays, April 10–May 15
Copyright © 2022 Assessment Technologies Institute®

LLC. All rights reserved. Images from the NCSBN
94 used with permission, 2020.

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What is the purpose of developing a new version of the NCLEX?

What is the purpose of developing a new version of the NCLEX?

What are some strategies discussed for preparing students for the new version of the NCLEX?

What are some strategies discussed for preparing students for the new version of the NCLEX?

Next Generation

NCLEX Guidebook 2022

Your reference for

Scan for the most

CLINICAL JUDGMENT 13 TEACHING STRATEGIES 50 NEW ITEM TYPES 69

COMING IN April 2023: A NEW VERSION OF THE NCLEX®......................... 6

STRATEGIES TO TEACH CLINICAL JUDGMENT.......................................... 50

DEVELOPING & ASSESSING CLINICAL JUDGMENT SKILLS....................... 83

HOW TO STAY UP-TO-DATE & GET YOUR QUESTIONS ANSWERED......... 93

We’ve gathered everything you need to know so

Share it with colleagues to help them

Nurses face more complex client needs

When you were in nursing school, The NCSBN confirmed this

Read more about the impact on

The plan for the Next Generation NCLEX has

In 2009, the NCSBN held The NCSBN’s studies underscored

Research is the backbone of the NCSBN’s plan.

The NCSBN’s team of researchers and

1) DEVELOP A CLINICAL 5) RESEARCH MEASUREMENT

This section of the current NCLEX is a crucial

Candidates’ answers provide data

DECEMBER 2022 APRIL 1, 2023 APRIL 2023

Clinical judgment is necessary when

The NCSBN’s observational What was especially worrisome

NCSBN Chief Officer

“A decade of performance-based development

Help students understand what it means.

The NCSBN has defined clinical judgment

Further, clinical judgment is an iterative

• Identify a prioritized client concern

Research provides insights on how to incorporate

Based on the research noted on • Deliver one-on-one interaction

• Make assignments that are

Help students develop clinical judgment skills

1) USE ACTIVE-LEARNING STRATEGIES.

3) QUESTION USING THE

CLARIFICATION JUSTIFICATION PROBING

Priority setting is directly related to clinical

Maslow's Hierarchy of Needs

A. Give the client simple

Airway – Breathing – Circulation

Which of the following actions is the

D. Place client on a cardiac monitor.

D. Attaching the client to a cardiac monitor is important, because medications used to

Safety & Risk Reduction

The Nursing Process

PN: 4 Steps RN: 5 Steps

Least Restrictive / Least Invasive

B. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as

C. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as

D. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as

Acute vs. Chronic / Unstable vs. Stable /

ACUTE VS. CHRONIC

UNSTABLE VS. STABLE

URGENT VS. NONURGENT

ACUTE VS. NONACUTE RATIONALES

ENVIRONMENTAL • C ultural considerations (i.e., language,

• Identify relevant information related

• C ompare client findings to evidence- • A nalyze client needs.

• O rganize client assessment

• P romptly and accurately perform • Incorporate client preferences and

• R eassess the client’s condition to determine achievement